Re: IgE 매개 음식 알레르기 논문..

[문형철]

음식에 대한 이상반응 탐구중...

순서는 이럴거 같다. 

1. Food intolerance  글루텐, 유당, 과당을 먼저 끊는다.

2. histamine intolerance 문제를 해결한다. 이 문제 탐구중

3. 심각하지는 않으면서 문제를 일으키는 food allergy 음식을 차단한다.

4. 활성산소를 제거하고 만성염증을 제거하는 각종 항산화 야채를 주로 먹는다

5. 칼로리는 좋은 지방(불포화지방, 오메가 3지방산)을 먹어 bhb를 에너지 대사로 산다.

https://www.youtube.com/watch?v=ibwcvScuj6Y

Volume 14 Supplement 2

Practical guide for allergy and immunology in Canada 2018

• Review
• Open access
• Published: 12 September 2018

IgE-mediated food allergy

• Susan Waserman, 
• Philippe Bégin & 
• Wade Watson 

Allergy, Asthma & Clinical Immunology volume 14, Article number: 55 (2018) Cite this article

•  
•  
•  
•  

Abstract

Food allergy is defined as an adverse immunologic response to a food protein. Food-related reactions are associated with a broad range of signs and symptoms that may involve any body system, including the skin, gastrointestinal and respiratory tracts, and cardiovascular system. Immunoglobulin E (IgE)-mediated food allergy is a leading cause of anaphylaxis and, therefore, referral to an allergist for timely and appropriate diagnosis and treatment is imperative. Diagnosis entails a careful history and diagnostic tests, such as skin prick tests, serum-specific IgE and, if indicated, an oral food challenge. Once the diagnosis of food allergy is confirmed, strict elimination of the offending food allergen from the diet is generally necessary; however, in the case of cow’s milk and egg allergy, many allergic children are able to eat these foods in their baked form. This article provides an overview of the epidemiology, pathophysiology, diagnosis, and management of IgE-mediated food allergy.

식품 알레르기는 

식품 단백질에 대한 면역학적 이상 반응으로 정의됩니다. 

식품 관련 반응은 

피부, 위장관 및 호흡기, 심혈관계 등 모든 신체 기관과 관련된 

광범위한 징후 및 증상과 관련이 있습니다. 

면역글로불린 E(IgE) 매개 식품 알레르기는 

아나필락시스의 주요 원인이므로 

적시에 적절한 진단과 치료를 위해 

알레르기 전문의에게 의뢰하는 것이 필수적입니다. 

진단을 위해서는 

면밀한 병력 청취와 

피부 단자 검사, 

혈청 특이 IgE, 

필요한 경우 경구 음식물 챌린지 등의 진단 검사가 필요합니다. 

식품 알레르기 진단이 확정되면 

일반적으로 식단에서 해당 식품 알레르겐을 철저히 제거해야 하지만, 

우유 및 계란 알레르기의 경우 

많은 알레르기 어린이가 구운 형태로 이러한 식품을 섭취할 수 있습니다. 

이 도움말에서는

 IgE 매개 식품 알레르기의 역학, 병태생리, 진단 및 관리에 대한 

개요를 제공합니다.

Background

IgE-mediated food allergy is a leading cause of anaphylaxis, a severe, potentially fatal allergic reaction presenting to emergency departments [1] (see article on Anaphylaxis in this supplement). A recent survey of over 5700 Canadian households (15,022 individuals) estimated the preval‎ence of food allergy in Canada to be 7.5% (self-reported; Table 1) [2]. Annually, approximately 200 deaths in the United States are attributed to food allergy [3]. A review of anaphylaxis deaths that occurred between 1986 and 2011 in Ontario, Canada, attributed 48% of these deaths to food allergy [4]. When comparing the time periods 1986–1998 and 1999–2011, fatalities due to food allergy declined from 28 to 12 cases, whereas fatalities due to medications and unknown causes increased (from 6 to 10 and from 1 to 5, respectively).

IgE 매개 식품 알레르기는 

응급실에 내원하는 심각하고 치명적인 알레르기 반응인 

아나필락시스의 주요 원인입니다[1](이 보충 자료의 아나필락시스 관련 기사 참조). 

최근 캐나다 5700여 가구(15,022명)를 대상으로 한 설문조사에 따르면 

캐나다의 식품 알레르기 유병률은 7.5%(자가 보고, 표 1)로 

추정됩니다[2]. 

미국에서는 

매년 약 200명이 식품 알레르기로 인해 사망합니다[3]. 

캐나다 온타리오주에서 

1986년부터 2011년 사이에 발생한 아나필락시스 사망자를 검토한 결과, 

이 중 48%가 

식품 알레르기로 인한 사망이었습니다[4]. 

1986-1998년과 1999-2011년을 비교했을 때 

식품 알레르기로 인한 사망자는 28건에서 12건으로 감소한 반면, 

약물 및 원인 불명으로 인한 사망자는 

각각 6건에서 10건, 1건에서 5건으로 증가했습니다.

Table 1 Preval‎ence (self-reported, unadjusted) estimates for probable food allergy in Canada [2]

Full size table

Accurate diagnosis and appropriate management of IgE-mediated food allergy are critical since accidental exposure to even minute quantities of the culprit food may result in anaphylaxis [5]. This review focuses primarily on IgE-mediated food-allergic reactions, and provides an overview of current literature related to the epidemiology, pathophysiology, diagnosis, and management of this type of food allergy.

원인 식품에 소량이라도 실수로 노출되면 

아나필락시스가 발생할 수 있으므로 

IgE 매개 식품 알레르기의 정확한 진단과 적절한 관리가 중요합니다[5]. 

이 리뷰에서는 

주로 IgE 매개 식품 알레르기 반응에 초점을 맞추고 

이러한 유형의 식품 알레르기의 역학, 

병태생리, 

진단 및 관리와 관련된 최신 문헌에 대한 개요를 

제공합니다.

Definition

The term food allergy is used to describe an adverse immunologic response to a food protein. It is important to distinguish food allergy from other non-immune-mediated adverse reactions to foods, particularly since more than 20% of adults and children alter their diets due to perceived food allergy [6].

Adverse reactions that are not classified as food allergy include

food intolerances secondary to metabolic disorders (e.g., lactose intolerance),

reactions to toxic contaminants (e.g., bacteria in decomposing scombroid fish will convert histidine, an amino acid, to histamine) or pharmacologically active food components (e.g., caffeine in coffee causing jitteriness, tyramine in aged cheeses triggering migraine).

식품 알레르기는 

식품 단백질에 대한 면역학적 이상 반응을 설명하는 데 사용됩니다. 

특히 성인과 어린이의 20% 이상이 

식품 알레르기로 인해 식단을 변경하기 때문에 

식품 알레르기를 

식품에 대한 다른 비면역 매개 이상 반응과 구별하는 것이 중요합니다[6]. 

식품 알레르기로 분류되지 않는 이상 반응에는

 대사 장애로 인한 이차적인 식품 과민증(예: 유당 불내증), 

독성 오염 물질에 대한 반응(예: scombroid fish를 분해하는 박테리아가 아미노산인 히스티딘을 히스타민으로 전환) 또는

 약리학적으로 활성 식품 성분(예: 커피의 카페인이 불안감을 유발하고 숙성 치즈의 티라민이 편두통을 유발)이 

포함됩니다.

Pathophysiology

Although food allergy can arise to any food, Health Canada has identified the following 10 priority allergens: cow’s milk (CM), egg, peanut, tree nuts, fish/shellfish, wheat, sesame seed, soy, mustard and sulphites (a food additive) [7]. Canadian food labeling regulations require food manufacturers to list these food allergens, gluten sources and added sulphites on food labels.

With the exception of a carbohydrate known as galactose-alpha-1,3-galactose (also known as alpha-gal), it is the protein component, not the fat or carbohydrate components, of these foods that leads to sensitization and allergy. The allergenic segments or epitopes of these proteins tend to be small (10–70 kd in size), water-soluble glycoproteins that have varying degrees of resistance to denaturation by heat or acid and, therefore, can remain intact even after processing, storage, cooking and digestion [5, 6, 8]. Examples of these glycoproteins include casein in CM, vicilin in peanut, and ovomucoid in egg. However, many children who are allergic to CM and egg can tolerate these foods when baked. In general, allergies to additives and preservatives are uncommon.

IgE antibody responses to alpha-gal results in a delayed allergic reaction to mammalian meat, and has been associated with anaphylaxis 3–6 h after ingestion of mammalian food products (e.g., beef and pork) [9]. It is the only example of IgE to a carbohydrate that has been associated with anaphylaxis. Studies strongly suggest that tick bites are the main cause of this IgE antibody response to alpha-gal, since ticks inject alpha gal through their saliva when biting humans [9].

Food-induced allergic disorders are broadly categorized into those mediated by IgE antibodies or by non-IgE-mediated mechanisms. IgE-mediated allergic responses are the most widely recognized form of food allergy and are characterized by the rapid onset of symptoms after ingestion. During initial “sensitization” to the food, consumption of the allergenic food protein stimulates production of food-specific IgE antibodies which then bind to tissue basophils and mast cells. When the causal foods are subsequently eaten, they bind to their specific IgE antibodies and trigger the release of mediators, such as histamine, prostaglandins and leukotrienes, causing “clinical reactivity” (allergic symptoms). It is important to note that sensitization can be present without clinical reactivity, meaning that specific IgE to a food is present, but no reaction occurs with food exposure [6, 8, 10, 11]. For a review of non-IgE-mediated (cell-mediated) food hypersensitivity, please see the article entitled Non-IgE-mediated Food Hypersensitivity in this supplement.

Disorders such as atopic dermatitis (AD), eosinophilic gastroenteritis, and eosinophilic esophagitis (EoE) may be associated with a mixed IgE-/cell-mediated mechanism of reactivity to food (see articles on EoE and AD in this supplement). In these disorders, the association with food may not be demonstrated in all patients.

The spectrum of food-allergy-associated disorders according to pathophysiology is shown in Fig. 1. It is important to note that food allergy is not a cause of conditions such as migraines, behavioural or developmental disorders, arthritis, seizures or inflammatory bowel disease.

식품 알레르기는 

모든 식품에서 발생할 수 있지만 캐나다 보건부는 

우유(CM), 계란, 땅콩, 견과류, 생선/조개류, 밀, 참깨, 대두, 겨자, 아황산염(식품 첨가물)[7]을 

우선순위 10가지 알레르겐으로 지정했습니다. 

캐나다 식품 라벨링 규정에 따라 

식품 제조업체는 

식품 라벨에 이러한 식품 알레르기 유발 물질, 

글루텐 공급원 및 

첨가 아황산염을 표시해야 합니다.

갈락토스-알파-1,3-갈락토스(알파갈이라고도 함)로 알려진 탄수화물을 제외하면 

이러한 식품의 지방이나 탄수화물 성분이 아닌 

단백질 성분이 

감작과 알레르기를 유발합니다. 

이러한 

단백질의 알레르기 유발 세그먼트 또는 에피토프는 

열이나 산에 의한 변성에 대한 저항성이 다양한 

수용성 당단백질로, 

가공, 보관, 조리 및 소화 후에도

 그대로 유지될 수 있는 작은 크기(10-70kd)의 

수용성 당단백질인 경향이 있습니다[5, 6, 8]. 

이러한 

당단백질의 예로는 

CM의 카제인, 

땅콩의 비실린, 

계란의 오보뮤코이드 등이 있습니다. 

 casein in CM,

vicilin in peanut, and

ovomucoid in egg

그러나 

CM과 계란에 알레르기가 있는 많은 어린이는 

이러한 식품을 구워도 견딜 수 있습니다. 

일반적으로 

첨가물 및 방부제에 대한 알레르기는 

흔하지 않습니다.

알파갈에 대한 IgE 항체 반응은 

포유류 육류에 대한 지연된 알레르기 반응을 일으키며 

포유류 식품(예: 소고기 및 돼지고기) 섭취 후 

3~6시간 후에 아나필락시스와 관련이 있습니다[9]. 

이는 

아나필락시스와 연관된 

탄수화물에 대한 IgE의 유일한 예입니다. 

진드기가 사람을 물 때 

침을 통해 알파갈을 주입하기 때문에 

진드기에 물린 것이 

알파갈에 대한 IgE 항체 반응의 주요 원인이라는 

연구 결과가 강력하게 제시되고 있습니다[9].

식품으로 인한 알레르기 질환은 

크게 IgE 항체에 의해 매개되는 경우와 

비 IgE 매개 메커니즘에 의해 매개되는 경우로 분류됩니다. 

IgE 매개 알레르기 반응은 

가장 널리 알려진 형태의 식품 알레르기이며, 

섭취 후 증상이 빠르게 시작되는 것이 특징입니다. 

음식에 대한 초기 "감작" 동안 

알레르기 유발 식품 단백질의 섭취는 

식품 특이 IgE 항체의 생성을 자극하여 

조직 호염기구와 비만 세포에 결합합니다. 

이후 원인 식품을 섭취하면 

특정 IgE 항체와 결합하여 

히스타민, 프로스타글란딘, 류코트리엔과 같은 

매개 물질의 방출을 유발하여 

"임상적 반응성"(알레르기 증상)을 유발합니다. 

감작성은 

임상적 반응성 없이도 존재할 수 있으며, 

이는 식품에 대한 특정 IgE가 존재하지만 식

품 노출 시 반응이 일어나지 않는다는 것을 의미합니다[6, 8, 10, 11]. 

비-IgE 매개(세포 매개) 식품 과민증에 대한 검토는 

이 보충 자료의 비-IgE 매개 식품 과민증 문서를 참조하세요.

아토피성 피부염(AD), 

호산구성 위장염, 

호산구성 식도염(EoE)과 같은 질환은 

음식에 대한 반응성의 IgE/세포 매개 혼합 메커니즘과 관련이 있을 수 있습니다(이 보충제의 EoE 및 AD에 대한 기사 참조). 

이러한 질환에서 

음식과의 연관성은 

모든 환자에서 입증되지 않을 수 있습니다.

병리 생리학에 따른 

식품 알레르기 관련 장애의 스펙트럼은 

그림 1에 나와 있습니다. 

식품 알레르기는 

편두통, 행동 또는 발달 장애, 관절염, 발작 또는 

염증성 장 질환과 같은 질환의 원인이 아니라는 점에 

유의해야 합니다.

Fig. 1

Spectrum of food allergy disorders according to pathophysiology [6, 8, 10]

Full size image

Natural history of food allergy

The natural history of food allergy varies by type of food allergen. CM and egg allergy can present in the 1st year of life, and although some children may outgrow these allergies by early school age, others may not develop tolerance until their teenage years. Studies have reported that 19% of subjects achieve tolerance to CM by age 4 years, 42% by age 8 years, 64% by age 12 years, and 79% by 16 years [12]. For egg allergy, 4% achieve tolerance by age 4 years, 12% by age 6 years, 37% by age 10 years, and 68% by age 16 years [13]. In contrast, allergy to peanut, tree nuts, fish, and shellfish are generally lifelong, although 20% of individuals may outgrow peanut allergy [14]. Peanut and tree nuts are responsible for the most serious allergic reactions and food-allergy related fatalities [15, 16].

Children with AD tend to have a higher preval‎ence of other atopic disorders including food allergy. Approximately 35% of children with moderate-to-severe AD have IgE-mediated food allergy [17], as well as a higher preval‎ence of allergic rhinitis (75%) and asthma (80%) [18]. Primary prevention in infants at increased risk of AD is discussed in this supplement (see Atopic Dermatitis article).

식품 알레르기의 자연사는 

식품 알레르겐의 종류에 따라 다릅니다. 

CM과 계란 알레르기는 

생후 1년에 나타날 수 있으며, 

일부 어린이는 취학 연령이 될 때까지 이러한 알레르기가 없어지지만 

다른 어린이는 10대가 될 때까지 내성이 생길 수 있습니다. 

연구에 따르면 

피험자의 19%는 4세, 42%는 8세, 64%는 12세, 79%는 16세까지 CM에 대한 내성을 보인다고 합니다[12]. 

계란 알레르기의 경우 

4세까지 4%, 6세까지 12%, 10세까지 37%, 16세까지 68%가 내성에 도달합니다[13]. 

반면 

땅콩, 견과류, 생선 및 조개류에 대한 알레르기는 

일반적으로 평생 지속되지만, 

20%는 땅콩 알레르기를 벗어날 수 있습니다[14]. 

땅콩과 견과류는 

가장 심각한 알레르기 반응과 

식품 알레르기 관련 사망의 원인이 됩니다[15, 16].



AD 아동은 

음식 알레르기를 포함한 다른 아토피 질환의 유병률이 

더 높은 경향이 있습니다. 

중등도-중증 AD 아동의 약 35%가 

IgE 매개 식품 알레르기를 가지고 있으며[17], 

알레르기 비염(75%) 및 천식(80%)의 유병률도 더 높습니다[18]. 

이 보충 자료에서는 

아토피 피부염의 위험이 높은 유아의 일차 예방에 대해 설명합니다(아토피 피부염 문서 참조).

Clinical manifestations

Food-related reactions are associated with a broad range of signs and symptoms that may involve any body system, including the skin, GI and respiratory tracts, and cardiovascular system (Table 2). Food allergy is not felt to play a role in chronic respiratory symptoms.

식품 관련 반응은 

피부, 위장관 및 호흡기, 심혈관계 등 

모든 신체 시스템과 관련된 광범위한 징후 및 증상과 관련이 있습니다(표 2). 

만성 호흡기 증상에는 

음식 알레르기가 영향을 미치지 않는 것으로 알려져 있습니다.

Table 2 Signs and symptoms of food allergy

Full size table

Skin reactions, including urticaria, angioedema and erythema, are the most common clinical manifestations of IgE-mediated allergy to food. Typical respiratory symptoms include laryngeal edema, rhinorrhea, and bronchospasm. GI-related signs and symptoms of food allergy include nausea, vomiting, abdominal pain, and diarrhea.

A localized IgE-mediated reaction is the oral allergy syndrome, also known as the pollen-food syndrome, which causes tingling and itching of the mouth and pharynx. This is typically triggered after consumption of certain fresh fruits and vegetables in pollen-allergic individuals. It is caused by cross reactivity between IgE antibodies to certain pollens with proteins in some fresh fruits and vegetables (see Table 3) [5]. For example, individuals with ragweed allergy may experience oropharyngeal symptoms following the ingestion of bananas or melons, and patients with birch pollen allergy may experience these symptoms following the ingestion of raw carrots, celery or apple. Fortunately, these proteins are heat labile, enabling allergic individuals to eat these foods when cooked. Allergy skin tests are usually negative to commercial food extracts in individuals with oral allergy syndrome, but are positive to the fresh or frozen food [19]. Also, progression to systemic symptoms is rare, but may occur in a small proportion of patients with this condition [6, 8, 20].

두드러기, 혈관 부종 및 홍반을 포함한 피부 반응은 

음식에 대한 IgE 매개 알레르기의 

가장 흔한 임상 증상입니다. 

전형적인 호흡기 증상으로는 

후두 부종, 콧물, 기관지 경련 등이 있습니다. 

음식 알레르기의 위장관 관련 징후 및 증상으로는 

메스꺼움, 구토, 복통, 설사 등이 있습니다.

국소적인 IgE 매개 반응으로는 

입과 인두의 따끔거림과 

가려움증을 유발하는 꽃가루 음식 증후군으로도 알려진 

구강 알레르기 증후군이 있습니다. 

이는 일반적으로 

꽃가루 알레르기가 있는 사람이 

특정 신선한 과일과 채소를 섭취한 후에 유발됩니다. 

이는 특정 꽃가루에 대한 

IgE 항체와 일부 신선한 과일 및 채소의 단백질 간의 

교차 반응으로 인해 발생합니다(표 3 참조)[5]. 

예를 들어 

돼지풀 알레르기가 있는 사람은 

바나나나 멜론을 섭취한 후 

구인두 증상을 경험할 수 있으며, 

자작나무 꽃가루 알레르기가 있는 환자는 

생당근, 셀러리 또는 사과를 섭취한 후 

이러한 증상을 경험할 수 있습니다. 

다행히도 이러한 단백질은 

열에 불안정하기 때문에 알레르기가 있는 사람도 

익혀서 섭취할 수 있습니다. 

알레르기 피부 테스트는 

일반적으로 

구강 알레르기 증후군 환자의 상업용 식품 추출물에 대해서는 

음성으로 나타나지만 

신선 식품이나 냉동 식품에 대해서는 양성으로 나타납니다[19]. 

또한 

전신 증상으로 진행되는 경우는 드물지만 

일부 환자에서 발생할 수 있습니다[6, 8, 20].

Table 3 Oral allergy syndrome: cross reaction between proteins in pollen and fresh fruits and vegetables [5]

Full size table

The most severe reaction is anaphylaxis, which is defined as a serious allergic reaction that is rapid in onset and may cause death. The clinical criteria for diagnosing anaphylaxis are shown in Table 4 [21,22,23]. There are numerous signs and symptoms of anaphylaxis which usually develop within minutes to 2 h after food exposure. Early symptoms should not be ignored since reactions can be highly unpredictable, and can vary from person to person, and even from attack to attack in the same person. Peanuts, tree nuts, shellfish, fish, CM, and eggs are the most common foods that cause anaphylaxis; however, any food can trigger an allergic reaction [5].

가장 심각한 반응은 

아나필락시스로, 

발병이 빠르고 사망을 초래할 수 있는 심각한 알레르기 반응으로 정의됩니다. 

아나필락시스 진단을 위한 임상 기준은 

표 4에 나와 있습니다[21,22,23]. 

아나필락시스의 징후와 증상은 다양하며 

일반적으로 식품 노출 후 

몇 분에서 2시간 이내에 발생합니다. 

반응은 매우 예측하기 어렵고 사람마다, 

심지어 같은 사람이라도 발작마다 다를 수 있으므로 

초기 증상을 무시해서는 안 됩니다. 

땅콩, 견과류, 조개류, 생선, CM, 계란이 

아나필락시스를 유발하는 가장 흔한 식품이지만 

모든 식품이 알레르기 반응을 일으킬 수 있습니다[5].

Table 4 Clinical criteria for diagnosing anaphylaxis [21,22,23]

Full size table

Diagnosis

The diagnosis of food allergy requires a detailed history and physical examination, as well as diagnostic tests such as skin prick tests (SPT) and/or food-specific serum IgE assessment. In some cases, an oral food challenge (OFC) may also be required [6, 8]. Referral to an allergist is important to confirm‎ the diagnosis of a suspected food allergy. Patients should avoid the food in question until assessment, and an epinephrine auto-injector (EAI) should be prescribed, even if the diagnosis is uncertain [5].

식품 알레르기를 진단하려면 

자세한 병력과 신체 검사는 물론 

피부 단자 검사(SPT) 및/또는 식품 특이 혈청 IgE 평가와 같은 진단 테스트가 필요합니다. 

경우에 따라 

경구 음식 챌린지(OFC)가 필요할 수도 있습니다[6, 8]. 

의심되는 식품 알레르기의 진단을 확인하려면 

알레르기 전문의에게 의뢰하는 것이 중요합니다. 

환자는 진단이 내려질 때까지 

해당 식품을 피해야 하며, 

진단이 불확실한 경우에도 에피네프린 자동 주사기(EAI)를 처방받아야 합니다[5].

History

It is important to inquire about all suspect foods and to discuss the manner of food preparation (e.g., cooked, raw, added spices or other ingredients). Time of onset of symptoms in relation to food exposure, symptom duration and severity, as well as reproducibility of symptoms in the case of recurrent exposure should be determined. It is also important to ask about factors that can potentiate an allergic reaction, such as exercise, non-steroidal anti-inflammatory drugs, or alcohol [6, 8]. Some patients will only experience a reaction when the allergen is eaten simultaneously with one of these co-factors [24].

의심되는 모든 음식에 대해 문의하고 

음식 조리 방식(예: 익힌 음식, 날 음식, 향신료 또는 기타 재료 첨가)에 대해 

논의하는 것이 중요합니다. 

식품 노출과 관련된 증상 발현 시간,

 증상 지속 시간 및 중증도, 

반복 노출 시 증상의 재현성을 확인해야 합니다. 

운동, 비스테로이드성 항염증제 또는 

알코올과 같이 알레르기 반응을 강화할 수 있는 요인에 대해 

물어보는 것도 중요합니다[6, 8]. 

일부 환자는 

이러한 보조 인자 중 하나와 알레르겐을 동시에 섭취했을 때만 

반응을 경험합니다[24].

Diagnostic tests

In general, diagnostic tests for food allergy (e.g., SPT, food-specific serum IgE, and OFCs) should be performed by an allergist. The SPT is a rapid, safe and sensitive method for diagnosing suspected IgE-mediated food allergy. A positive SPT appears as a wheal and flare reaction when the responsible food is applied to the skin and pricked. A positive SPT has a sensitivity of approximately 90%; however, its specificity is only around 50%. Therefore, a positive SPT alone is not sufficient for diagnosing food allergy; the patient must also have a supportive history. To minimize false positive results, over-testing with SPT should be avoided. SPT should only be done for those foods that are implicated by the patient’s history. The negative predictive value of SPT is greater than 95%. Therefore, a negative SPT generally confirm‎s the absence of IgE-mediated reactions [6, 20]. Although less sensitive and more costly than SPTs, food-specific IgE can also be measured in serum for diagnosing food allergy, particularly if SPTs cannot be performed or are not available [6], as well as to help determine when an allergy is outgrown.

Component resolved diagnostic testing (CRD) is a relatively new method (blood test) to determine the risk or severity of allergic reactions to specific foods (e.g., peanut, hazelnuts, CM, egg, etc.). CRD can also identify cross-reactive specific components to other similar allergens from different pollen species or foods. For peanut, Ara h 8 is positive in those experiencing an oral allergy syndrome, whereas Ara h 2 is the most consistent marker for predicting peanut allergy. However, the diagnostic accuracy of a specific level of serum IgE to Ara h 2 varies between studies [25].

If the diagnosis is uncertain based on SPT and/or food allergen-specific IgE results, but there is still clinical suspicion of food allergy, an OFC may be appropriate. OFC involves gradual feeding of the suspected food with medically supervised assessment for any symptoms. In the event of symptoms, feeding is discontinued and the patient is treated where appropriate.

OFCs should only be conducted by a healthcare provider, usually an allergist, who is experienced with food allergy and anaphylaxis management, and who has established procedures for conducting these challenges [26]. In addition, OFCs must be conducted in a proper office- or hospital-based setting with resuscitation equipment. Documentation of informed consent prior to the challenge should detail that the risks and benefits of the procedure were explained to the patient or caregiver, and that these risks were understood. Healthcare providers conducting OFCs should also have an established plan for advising the patient based on the outcome of the challenge.

Other strategies that can help assist in the diagnosis of food allergy are elimination diets and food/symptom diaries. The elimination diet can be used for both the diagnosis and treatment of food allergy and requires complete avoidance of suspected foods or groups of foods for a given period of time (usually 1–2 weeks) while monitoring for an associated decrease in symptoms. It is limited by potential patient and physician bias as well as variable patient adherence to the diet. Therefore, an elimination diet should only be undertaken under the supervision of an experienced medical professional. Food/symptom diaries require the patient to keep a chronological record of all foods eaten and any associated adverse symptoms. These records may be helpful for identifying the food implicated in an adverse reaction; however, they are not usually diagnostic, particularly when symptoms are delayed or infrequent [6, 8].

일반적으로 

식품 알레르기 진단 검사(예: SPT, 식품 특이 혈청 IgE, OFC)는 

알레르기 전문의가 실시해야 합니다. 

SPT는 

의심되는 IgE 매개 식품 알레르기를 진단하는 

빠르고 안전하며 민감한 방법입니다. 

SPT 양성 반응은 

해당 식품을 피부에 바르고 찔렀을 때 

발진 및 발적 반응으로 나타납니다. 

양성 SPT의 민감도는 

약 90%이지만 특이도는 약 50%에 불과합니다. 

따라서 

SPT 양성 반응만으로는 

식품 알레르기를 진단하기에 충분하지 않으며, 

환자의 병력이 뒷받침되어야 합니다. 

위양성 결과를 최소화하려면 

SPT를 이용한 과도한 검사는 피해야 합니다. 

SPT는 

환자의 병력과 연관된 식품에 대해서만 실시해야 합니다. 

SPT의 음성 예측값은 95% 이상입니다. 

따라서 

SPT 음성은 

일반적으로 IgE 매개 반응이 없음을 확인합니다[6, 20]. 

SPT보다 덜 민감하고 비용이 많이 들지만, 

식품 특이 IgE는 특히 SPT를 수행할 수 없거나 사용할 수 없는 경우[6] 식

품 알레르기 진단을 위해 혈청에서 측정할 수 있으며 

알레르기가 언제 발생했는지 확인하는 데 도움이 될 수 있습니다.

성분 확인 진단 검사(CRD)는 

특정 식품(예: 땅콩, 헤이즐넛, CM, 계란 등)에 대한 

알레르기 반응의 위험성 또는 심각성을 판단하는 

비교적 새로운 방법(혈액 검사)입니다. 

CRD는 또한 다른 꽃가루 종이나 식품의 다른 유사한 알레르겐에 대한 교차 반응성 특정 성분을 식별할 수 있습니다. 땅콩의 경우, 경구 알레르기 증후군을 경험하는 사람들에게는 Ara h 8이 양성인 반면, 땅콩 알레르기를 예측하는 가장 일관된 마커는 Ara h 2입니다. 그러나 Ara h 2에 대한 특정 수준의 혈청 IgE의 진단 정확도는 연구마다 다릅니다[25].



SPT 및/또는 식품 알레르겐 특이 IgE 결과에 따라 진단이 불확실하지만 여전히 임상적으로 식품 알레르기가 의심되는 경우 OFC가 적절할 수 있습니다. OFC는 의심되는 식품을 점진적으로 먹이면서 증상이 있는지 의료진의 감독 하에 평가하는 것입니다. 증상이 나타나면 수유를 중단하고 적절한 치료를 받아야 합니다.

OFC는 식품 알레르기 및 아나필락시스 관리에 경험이 있고 이러한 검사 절차를 확립한 의료진(일반적으로 알레르기 전문의)에 의해서만 실시해야 합니다[26]. 또한, OFC는 소생 장비를 갖춘 적절한 사무실 또는 병원 기반 환경에서 실시해야 합니다. 챌린지 실시 전 사전 동의 문서에는 환자 또는 간병인에게 시술의 위험과 이점에 대해 설명하고 이러한 위험을 이해했음을 자세히 설명해야 합니다. 또한 OFC를 수행하는 의료진은 챌린지 결과에 따라 환자에게 조언할 계획을 수립해야 합니다.



식품 알레르기 진단에 도움이 될 수 있는 다른 전략으로는 

제거 식단과 식품/증상 일기가 있습니다. 

제거 식단은 

식품 알레르기의 진단과 치료 모두에 사용할 수 있으며, 

일정 기간(보통 1~2주) 동안 의심되는 식품 또는 식품군을 완전히 피하면서 

관련 증상 감소를 모니터링해야 합니다. 

이는 잠재적인 환자와 

의사의 편견과 환자의 식단 준수 여부에 따라 달

라질 수 있다는 한계가 있습니다. 

따라서 

숙련된 의료 전문가의 감독 아래에서만 

제거 식단을 진행해야 합니다. 

음식/증상 일기는 

환자가 섭취한 모든 음식과 관련 이상 증상을 

시간순으로 기록해야 합니다. 

이러한 기록은 

이상 반응과 관련된 식품을 식별하는 데 도움이 될 수 있지만, 

특히 증상이 지연되거나 드물게 나타나는 경우에는 일반적으로 진단에 도움이 되지 않습니다[6, 8].

Treatment

A simplified algorithm for the diagnosis and management of food allergy is provided in Fig. 2.

Fig. 2

Simplified algorithm for the diagnosis and management of food allergy. IgE immunoglobulin E

Full size image

Food avoidance

Once a food allergy is diagnosed, strict elimination of the offending food allergen from the diet is necessary. A properly managed, well-balanced elimination diet will keep an individual free of symptoms while maintaining nutritional status. When the elimination diet is used as treatment, the relevant food should only be reintroduced once evidence exists that the food allergy has resolved [6, 8].

식품 알레르기가 진단되면 

식단에서 알레르기를 일으키는 식품 알레르겐을 

엄격하게 제거해야 합니다. 

적절하게 관리되고 균형 잡힌 제거 식단은 

영양 상태를 유지하면서 증상을 완화할 수 있습니다. 

제거 식단을 치료법으로 사용하는 경우, 

식품 알레르기가 해결되었다는 증거가 있는 경우에만 

관련 식품을 다시 도입해야 합니다[6, 8].

Pharmacotherapy

In case of accidental exposure, the treatment of choice is epinephrine administered by intramuscular injection into the lateral thigh [6, 8]. There is currently one epinephrine auto-injector (EAI) in Canada, EpiPen®, which is available in two dosages (0.15 and 0.30 mg) and is prescribed according to weight. The 0.30-mg dosage should be used for those weighing 30 kg or more, and the 0.15-mg dosage for children weighing between 15 and 30 kg [27]. The American Academy of Pediatrics (AAP) recommends switching most children from the 0.15-mg dose to the 0.3-mg dose when they reach a body weight of > 25 kg [28].

These devices should be stored properly (avoiding temperature extremes) and replaced before the expiration date. More information on EAIs is available at http://www.epipen.ca. All individuals receiving emergency epinephrine must be transported to hospital immediately (ideally by ambulance) for eval‎uation and observation [29].

A concise, written action plan for the treatment of allergic reactions resulting from accidental exposure to the food should be developed, and copies made available to the appropriate persons (e.g., caregivers, daycare providers, teachers, employers). Examples of action plans can be downloaded at Food Allergy Canada (http://foodallergycanada.ca/resources/national-guidelines/).

Patients and their caregivers must be educated on food avoidance, the recognition and treatment of allergic and anaphylactic reactions, the appropriate use of EAIs, and how to obtain immediate medical assistance. Individuals should also be instructed to read food labels carefully, watching for hidden ingredients such as “natural flavour” or “spices” that may contain allergens, as well as “may contain” warnings. Consultation with a registered dietitian may be beneficial in this regard and may help prevent further reactions [30]. All food-allergic patients should wear medical identification, such as a MedicAlert® bracelet/necklace, indicating their food allergy [5].

Food allergy is associated with a significant psychosocial burden for patients and families, which can lead to social limitations, hypervigilance and anxiety. Patients or parents with extreme anxiety or symptoms of post-traumatic stress disorder following life-threatening reactions should be referred for professional support [31].

우발적 노출의 경우, 

허벅지 측면에 근육 주사로 

에피네프린을 투여하는 치료법이 선택됩니다[6, 8]. 

현재 캐나다에는 

에피네프린 자동 주사기(EAI)인 에피펜®이 하나 있으며, 

두 가지 용량(0.15 및 0.30mg)으로 제공되며 체중에 따라 처방됩니다. 0.30mg 용량은 체중이 30kg 이상인 경우, 0.15mg 용량은 체중이 15~30kg인 어린이에게 사용해야 합니다[27]. 미국 소아과 학회(AAP)에서는 대부분의 어린이가 체중이 25kg을 초과하면 0.15mg 용량에서 0.3mg 용량으로 전환할 것을 권장합니다[28].

이러한 디바이스는 극한 온도를 피하여 적절히 보관하고 유효기간이 지나기 전에 교체해야 합니다. EAI에 대한 자세한 정보는 http://www.epipen.ca 에서 확인할 수 있습니다. 응급 에피네프린을 투여받은 모든 사람은 평가와 관찰을 위해 즉시 병원으로 이송(구급차 이용이 이상적)해야 합니다[29].

우발적인 식품 노출로 인한 

알레르기 반응 치료를 위한 

간결하고 서면화된 행동 계획을 수립하고 

사본을 적절한 사람(예: 간병인, 어린이집 제공자, 교사, 고용주)에게 제공해야 합니다. 

행동 계획의 예는 

캐나다 식품 알레르기(http://foodallergycanada.ca/resources/national-guidelines/)에서 다운로드할 수 있습니다.

환자와 간병인은 

식품 회피, 

알레르기 및 아나필락시스 반응의 인식 및 치료, 

EAI의 적절한 사용, 

즉각적인 의료 지원을 받는 방법에 대해 교육받아야 합니다. 

또한 식품 라벨을 주의 깊게 읽고 

알레르기 유발 물질을 함유할 수 있는 

'천연 향료' 또는 '향신료'와 같은 숨겨진 성분과 

'함유 가능' 경고 문구를 주의 깊게 읽도록 교육해야 합니다. 

이와 관련하여 공인 영양사와 상담하는 것이 도움이 될 수 있으며 추가 반응을 예방하는 데 도움이 될 수 있습니다[30]. 모든 식품 알레르기가 있는 환자는 식품 알레르기를 나타내는 MedicAlert® 팔찌/목걸이와 같은 의료용 신분증을 착용해야 합니다[5].

식품 알레르기는 환자와 가족에게 상당한 심리사회적 부담과 관련이 있으며, 이는 사회적 제한, 과잉 경계 및 불안으로 이어질 수 있습니다. 생명을 위협하는 반응 후 극심한 불안이나 외상 후 스트레스 장애 증상이 있는 환자나 부모는 전문가의 도움을 받아야 합니다[31].

Food desensitization

At present, there is no treatment for food allergy beyond avoidance of the culprit food and carriage of epinephrine, however, current research is focused on food desensitization. In desensitization, patients do not react to the food allergen but are continuing to receive treatment with the food on a regular basis. With tolerance (also known as sustained unresponsiveness), patients have stopped treatment and continue not to react to the food allergen.

Oral, epicutaneous and sublingual routes of food desensitization administration have been investigated. Reported rates of patient desensitization vary from 35% to 100% (intention to treat), with much lower rates noted for sustained unresponsiveness [32]. Although commercial products are expected to become available in the near future, there are currently no approved products in Canada. Hence, these treatments are primarily available through research protocols.

현재로서는 

원인 식품을 피하고 

에피네프린을 투여하는 것 외에 식

품 알레르기를 치료할 수 있는 방법은 없지만, 

현재 연구는 식품 탈감작에 초점을 맞추고 있습니다. 

탈감작 상태에서는 

환자가 음식 알레르겐에 반응하지 않지만 

정기적으로 해당 음식에 대한 치료를 계속 받습니다. 

내성(지속적 무반응이라고도 함)은 

환자가 치료를 중단하고 음식 알레르겐에 계속 반응하지 않는 상태를 말합니다.

경구, 표피 및 설하 투여 경로에 대한 식품 탈감작 투여가 조사되었습니다. 보고된 환자의 탈감작 비율은 35%에서 100%(치료 의향)까지 다양하며, 지속적인 무반응의 경우 훨씬 낮은 비율로 나타났습니다[32]. 가까운 시일 내에 상용 제품이 출시될 것으로 예상되지만, 현재 캐나다에는 승인된 제품이 없습니다. 따라서 이러한 치료법은 주로 연구 프로토콜을 통해 이용할 수 있습니다.

Oral immunotherapy

In oral immunotherapy (OIT), the food is slowly introduced under medical supervision, and the dose of food increased every 2 weeks until a predefined maintenance dose is reached. With the exception of the biweekly dose escalations, daily dosing is done at home. A maintenance dose is then eaten every day to maintain desensitization. Efficacy is determined by an OFC to the food in question. While multiple randomized control trials have confirmed that OIT is often effective for inducing desensitization to various food allergens, this treatment is also associated with a risk of reactions to the food doses [33].

Most patients experience mild adverse events (e.g., oropharyngeal pruritus, GI symptoms) that resolve without treatment or with oral antihistamines. However, adverse reactions requiring epinephrine may occur during OIT. Therefore, all patients must be equipped with an EAI and an emergency action plan. Approximately 2.7% of those treated with OIT in clinical trials develop EoE [34].

Although desensitization is not a cure, studies indicate improved quality of life and less anxiety for those who have completed this process. Some allergy societies have included OIT as part of their food allergy practice guidelines, but recommend that, at present, it be restricted to experienced professionals in specialized centres [35, 36].

Recently, investigators in Australia have reported on the long-term outcomes of combined probiotic and peanut oral immunotherapy (PPOIT). These investigators had previously reported on the findings of an 18-month randomized controlled trial which found that, compared to placebo, PPOIT was effective in inducing desensitization and 2-week sustained unresponsiveness in children with peanut allergy [37]. A follow-up study, which included 48 patients from this original trial (24 from the PPOIT group and 24 from the placebo group), was designed to assess whether the previously reported benefits of PPOIT were maintained 4 years after treatment cessation [38]. The follow-up study found that 67% of subject from the PPOIT group (16 of 24) were still eating peanut 4 years after stopping study treatment, compared to 4% of subjects from the placebo group (1 of 24). A substudy of 27 participants (12 from the PPOIT group and 15 from placebo group) that agreed to undergo food challenges to assess sustained unresponsiveness, showed that 58% of participants from the PPOIT group (7 of 12) attained 8-week sustained unresponsiveness, compared with 7% of participants from the placebo group (1 of 15). These data are consistent with other clinical trials of peanut OIT since, in the 4 years of follow up, the majority of active treatment subjects continued to eat peanut, thereby maintaining their desensitization. Furthermore, the efficacy of probiotics in PPOIT cannot be determined since the original randomized trial did not include a group that received peanut OIT without probiotics nor a group that received probiotics alone.

경구 면역 요법(OIT)에서는 

의료진의 감독 하에 식품을 천천히 도입하고, 

미리 정의된 유지 용량에 도달할 때까지 2주마다 식품의 용량을 늘립니다. 

격주로 용량을 증량하는 경우를 제외하고는 

매일 집에서 투약합니다. 

그런 다음 탈감작을 유지하기 위해 매일 유지 용량을 섭취합니다. 

효능은 해당 식품에 대한 OFC에 의해 결정됩니다. 여러 무작위 대조 시험에서 OIT가 다양한 식품 알레르겐에 대한 탈감작을 유도하는 데 효과적이라는 것이 확인되었지만, 이 치료법은 식품 투여량에 대한 반응의 위험과도 관련이 있습니다 [33].

대부분의 환자는 경미한 부작용(예: 구인두 소양증, 위장관 증상)을 경험하며, 이는 치료 없이 또는 경구 항히스타민제로 해결됩니다. 그러나 에피네프린이 필요한 이상 반응이 OIT 중에 발생할 수 있습니다. 따라서 모든 환자는 EAI와 응급 조치 계획을 갖추고 있어야 합니다. 임상시험에서 OIT로 치료받은 환자의 약 2.7%에서 EoE가 발생합니다[34].

탈감작이 완치는 아니지만, 연구 결과에 따르면 이 과정을 완료한 사람들은 삶의 질이 향상되고 불안감이 줄어드는 것으로 나타났습니다. 일부 알레르기 학회에서는 식품 알레르기 진료 지침에 OIT를 포함시켰지만, 현재로서는 전문 센터의 숙련된 전문가에게만 제한적으로 시행할 것을 권장하고 있습니다[35, 36].

최근 호주의 연구자들은 

프로바이오틱스와 

땅콩 경구 면역 요법(PPOIT)을 병행한 장기적인 결과에 대해 보고했습니다. 

이 연구자들은 이전에 땅콩 알레르기가 있는 어린이에게 위약과 비교하여 PPOIT가 탈감작과 2주간의 지속적인 무반응을 유도하는 데 효과적이라는 18개월의 무작위 대조 시험 결과를 보고한 적이 있습니다[37]. 이 오리지널 임상시험의 환자 48명(PPOIT 그룹 24명, 위약 그룹 24명)을 대상으로 한 후속 연구는 치료 중단 4년 후에도 이전에 보고된 PPOIT의 이점이 유지되는지 평가하기 위해 설계되었습니다[38]. 후속 연구 결과, 연구 치료를 중단한 지 4년이 지난 후에도 땅콩을 계속 섭취한 피험자는 PPOIT 그룹의 67%(24명 중 16명)인 반면, 위약 그룹의 피험자는 4%(24명 중 1명)에 불과한 것으로 나타났습니다. 지속적 무반응을 평가하기 위해 음식 도전에 동의한 27명의 참가자(PPOIT 그룹 12명, 위약 그룹 15명)를 대상으로 한 하위 연구 결과, PPOIT 그룹 참가자의 58%(12명 중 7명)가 8주 동안 지속적 무반응에 도달한 반면, 위약 그룹 참가자의 7%(15명 중 1명)만이 8주 동안 지속적 무반응에 도달한 것으로 나타났습니다. 이러한 데이터는 땅콩 OIT에 대한 다른 임상 시험과도 일치하는데, 4년의 추적 관찰 기간 동안 대부분의 활성 치료 대상자가 땅콩을 계속 섭취하여 탈감작을 유지했기 때문입니다. 또한, 원래의 무작위 시험에는 프로바이오틱스 없이 땅콩 OIT를 섭취한 그룹이나 프로바이오틱스만 섭취한 그룹이 포함되지 않았기 때문에 PPOIT에서 프로바이오틱스의 효능을 확인할 수 없습니다.

Epicutaneous immunotherapy

In epicutaneous immunotherapy (EPIT), the food is contained in a patch which is applied to the skin. A study of peanut allergic subjects aged 4–25 years found that treatment with 250 μg peanut patches was safe and associated with a modest response after 52 weeks, with the highest responses noted in younger children [39]. An extension study that included 18 children treated with 250 μg peanut patches for 3 years revealed a trend toward better treatment responses with long-term therapy, with no decrease in adherence or increase in adverse events [40]. A 95% overall adherence rate was observed throughout the study, and no serious adverse events or epinephrine use due to therapy was reported over the 3-year study period. Most adverse events were related to the application site; skin changes were mild to moderate and decreased in both severity and frequency over time.

Sublingual immunotherapy

Desensitization by sublingual immunotherapy (SLIT) utilizes dissolvable tablets or liquid allergen extracts that are placed daily under the tongue and held in place for several minutes before spitting out or swallowing. Although associated with less adverse events than OIT, SLIT is generally not as efficacious [32].

경피 면역 요법

경피 면역 요법(EPIT)에서는 피부에 붙이는 패치에 식품이 들어 있습니다. 4~25세의 땅콩 알레르기 환자를 대상으로 한 연구에 따르면 250μg 땅콩 패치를 사용한 치료는 안전하고 52주 후에 완만한 반응과 관련이 있으며, 어린 아이들에게서 가장 높은 반응이 나타났습니다[39]. 3년간 250μg 땅콩 패치로 치료받은 18명의 어린이를 대상으로 한 연장 연구에서는 장기 치료 시 순응도 감소나 부작용 증가 없이 치료 반응이 개선되는 추세가 나타났습니다[40]. 연구 기간 내내 95%의 전체 순응도가 관찰되었으며, 3년의 연구 기간 동안 치료로 인한 심각한 부작용이나 에피네프린 사용은 보고되지 않았습니다. 대부분의 부작용은 도포 부위와 관련된 것으로, 피부 변화는 경증에서 중등도였으며 시간이 지남에 따라 심각도와 빈도가 모두 감소했습니다.



설하 면역 요법

설하 면역 요법(SLIT)에 의한 탈감작 요법은 용해성 정제 또는 액체 알레르겐 추출물을 사용하여 매일 혀 아래에 놓고 뱉거나 삼키기 전에 몇 분 동안 유지합니다. SLIT는 OIT보다 부작용이 적지만 일반적으로 그다지 효과적이지 않습니다[32].

Baked egg and cow’s milk (CM)

Studies have shown that 69–83% of CM-allergic children can tolerate baked CM, and 63–83% of egg-allergic children can tolerate baked egg [41]. The introduction of baked egg or CM has also been shown to significantly increase rates of oral tolerance to the raw forms of these foods [42, 43].

연구에 따르면 CM 알레르기 어린이의 69-83%가 구운 CM을 견딜 수 있고, 계란 알레르기 어린이의 63-83%가 구운 계란을 견딜 수 있는 것으로 나타났습니다 [41]. 구운 달걀 또는 CM을 도입하면 이러한 식품의 원시 형태에 대한 경구 내성 비율도 크게 증가하는 것으로 나타났습니다 [42, 43].

Prevention of food allergy

Early introduction of food

According to current guidelines, an infant with at least one first-degree relative (parent or sibling) with a history of allergic disease such as allergic rhinitis, asthma, eczema, or food allergy is at greater risk of developing food allergy [44]. Observational studies suggest that the early introduction of peanut, egg, or CM may prevent the development of allergy to these foods [45,46,47] (for a more detailed discussion of this topic, please see article entitled Early Introduction of Foods to Prevent Food Allergy in this supplement). The Learning Early About Peanut (LEAP) trial showed that the early consumption of peanut in high-risk infants (defined as those with severe eczema and/or egg allergy) reduced the development of peanut allergy by 86% by 5 years of age [48]. The Persistence of Oral Tolerance to Peanut (LEAP-On) follow-up study investigated whether participants who had consumed peanut in the primary trial would remain protected from peanut allergy after cessation of peanut consumption for 12 months [49]. The LEAP-On investigators found that the benefits of early peanut introduction persisted after 12 months of cessation of peanut consumption. Based on the LEAP findings, updated AAP-endorsed guidelines outline a new approach to reducing the risk of peanut allergy (see Table 5) [50].

현재 가이드라인에 따르면 

알레르기 비염, 천식, 습진 또는 

식품 알레르기와 같은 알레르기 질환 병력이 있는

 1급 친척(부모 또는 형제자매)이 1명 이상 있는 유아는 

식품 알레르기 발병 위험이 더 높습니다[44]. 

관찰 연구에 따르면 

땅콩, 달걀 또는 CM을 조기에 도입하면 

이러한 식품에 대한 알레르기 발생을 예방할 수 있다고 합니다[45,46,47](이 주제에 대한 자세한 내용은 이 보충 자료의 식품 알레르기 예방을 위한 식품 조기 도입이라는 제목의 글을 참조하세요). 

땅콩에 대해 일찍 배우기(LEAP) 시험에 따르면 고위험군 유아(중증 습진 및/또는 계란 알레르기가 있는 유아로 정의)가 땅콩을 일찍 섭취하면 5세까지 땅콩 알레르기 발병이 86% 감소하는 것으로 나타났습니다[48]. 땅콩에 대한 경구 내성 지속성(LEAP-On) 후속 연구에서는 1차 시험에서 땅콩을 섭취한 참가자들이 12개월 동안 땅콩 섭취를 중단한 후에도 땅콩 알레르기로부터 보호받을 수 있는지 여부를 조사했습니다[49]. LEAP-On 연구진은 땅콩 섭취를 중단한 지 12개월이 지난 후에도 조기 땅콩 도입의 이점이 지속된다는 사실을 발견했습니다. LEAP 연구 결과를 바탕으로 업데이트된 AAP 승인 가이드라인에서는 땅콩 알레르기 위험을 줄이기 위한 새로운 접근법을 제시하고 있습니다(표 5 참조)[50].

Table 5 Summary of Addendum Guidelines 1, 2, and 3 [50]

Full size table

The Enquiring about Tolerance (EAT) trial hypothesized that the early introduction of six allergenic foods (peanut, cooked egg, CM, sesame, whitefish, and wheat) in exclusively breastfed infants who were 3 months of age (early introduction group) would reduce the preval‎ence of food allergy by age 3 years compared to infants who were exclusively breastfed for 6 months (standard introduction group) [51]. The intention-to-treat analysis revealed a 20% reduction in the preval‎ence of food allergy in the early introduction group that was not statistically significant, likely because of the high rate of non-adherence to the dietary protocol.

CM, 참깨, 흰살 생선, 밀)을 

생후 3개월에 모유만 먹인 유아(조기 도입 그룹)는 6개월 동안 모유만 먹인 유아(표준 도입 그룹)에 비해 3세까지 식품 알레르기 유병률이 감소할 것으로 나타났습니다[51]. 치료 의도 분석 결과 조기 도입 그룹에서 식품 알레르기 유병률이 20% 감소한 것으로 나타났는데, 이는 식이 프로토콜을 준수하지 않는 비율이 높았기 때문에 통계적으로 유의하지 않은 것으로 보입니다.

Use of probiotics/prebiotics

The World Allergy Organization/McMaster University Guidelines for Allergic Disease Prevention (GLAD-P) provide graded recommendations on the use of probiotics and prebiotics for allergy prevention based on current available evidence [52, 53]. GLAD-P recommends the use of probiotics in pregnant and breastfeeding women whose children and infants are at high risk for developing allergy (conditional recommendation, very low quality evidence) [52]. Ultimately, the use of probiotics should be individualized, and further studies are needed to eval‎uate their efficacy in preventing other types of allergy, as well as the differences among the strains of the same species of probiotic bacteria. The guidelines do not to provide a recommendation regarding prebiotic supplementation in pregnancy or during breastfeeding due to the lack of experimental and observational studies [53].

세계 알레르기 기구/맥마스터 대학교 알레르기 질환 예방 가이드라인(GLAD-P)은 현재 이용 가능한 증거를 바탕으로 알레르기 예방을 위한 프로바이오틱스와 프리바이오틱스 사용에 대한 등급별 권장 사항을 제공합니다 [52, 53]. 

GLAD-P는 알레르기 발병 위험이 높은 

임산부 및 모유 수유 여성에게 프로바이오틱스 사용을 권장합니다(조건부 권고, 근거 수준이 매우 낮음)[52]. 

궁극적으로 프로바이오틱스의 사용은 개별화되어야 하며, 

다른 유형의 알레르기 예방에 대한 효능과 동일한 종의 프로바이오틱스 박테리아 균주 간의 차이점을 평가하기 위한 추가 연구가 필요합니다. 이 가이드라인은 실험 및 관찰 연구가 부족하기 때문에 임신 중 또는 모유 수유 중 프리바이오틱스 보충제에 대한 권장 사항을 제공하지 않습니다[53].

Prognosis

The prognosis of food allergy is complex and dependent on the particular food. Although most infants and young children outgrow allergies to CM, egg, soy and wheat, there is evidence that an increasing number of children may not outgrow allergies to CM and egg until their teenage years [12, 13]. Children should be re-eval‎uated by their allergist at regular intervals to determine whether clinical tolerance has developed. In most cases, allergy to peanut, tree nuts, fish, and shellfish is lifelong.

식품 알레르기의 예후는 복잡하며 특정 식품에 따라 달라집니다. 대부분의 영유아가 CM, 계란, 대두, 밀에 대한 알레르기를 극복하지만, 점점 더 많은 어린이가 10대가 될 때까지 CM과 계란에 대한 알레르기를 극복하지 못할 수 있다는 증거가 있습니다[12, 13]. 어린이는 정기적으로 알레르기 전문의에게 재평가를 받아 임상적 내성이 생겼는지 확인해야 합니다. 대부분의 경우 땅콩, 견과류, 생선 및 조개류에 대한 알레르기는 평생 지속됩니다.

Conclusions

IgE-mediated food allergy is an important clinical problem of increasing preval‎ence. Assessment by an allergist is essential for appropriate diagnosis and treatment. Diagnosis is based on a careful history and diagnostic tests, such as SPT, food-specific serum IgE testing (where appropriate) and, if indicated, OFCs. The mainstay of treatment is avoidance of the responsible food(s), and timely administration of epinephrine for allergic reactions. Current research on treatment is focused on food desensitization. Further insights into the pathophysiology of food allergy and anaphylaxis will lead to the development of improved methods for prevention, diagnosis, and management.

IgE 매개 식품 알레르기는 

유병률이 증가하는 중요한 임상 문제입니다. 

적절한 진단과 치료를 위해서는 알레르기 전문의의 평가가 필수적입니다. 진단은 면밀한 병력 청취와 SPT, 식품 특이 혈청 IgE 검사(해당되는 경우), 필요한 경우 OFC와 같은 진단 검사를 기반으로 합니다. 치료의 중심은 원인 식품을 피하고 알레르기 반응에 대한 에피네프린을 적시에 투여하는 것입니다. 현재 치료에 대한 연구는 식품 탈감작에 초점을 맞추고 있습니다. 식품 알레르기 및 아나필락시스의 병태생리에 대한 더 많은 통찰력은 예방, 진단 및 관리를 위한 개선된 방법의 개발로 이어질 것입니다.

Key take-home messages

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Abbreviations

IgE:

immunoglobulin E

SPT:

skin prick tests

OFC:

oral food challenge

CM:

cow’s milk

AD:

atopic dermatitis

EoE:

eosinophilic esophagitis

GI:

gastrointestinal

EAI:

epinephrine auto-injector

OIT:

oral immunotherapy

EPIT:

epicutaneous immunotherapy

SLIT:

sublingual immunotherapy

LEAP:

Learning Early About Peanut study

LEAP-On:

Persistence of Oral Tolerance to Peanut follow-up study

EAT:

Enquiring About Tolerance study

GLAD-P:

World Allergy Organization-McMaster University Guidelines for Allergic Disease Prevention

CRD:

component resolved diagnostic testing

AAP:

American Academy of Pediatrics

PPOIT:

combined probiotic and peanut oral immunotherapy

References

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